Janet Golden, PhD, Professor of history, Rutgers University-Camden

The disease is terrifying. Many of the stricken are left in the streets to die horrible deaths, their bodies unclaimed. Thousands flee. The government appears helpless to stop the scourge from spreading. Physicians and nurses offer care, but have no effective methods of treatment or means to prevent the disease.

For centuries, yellow fever appeared in the U.S., spreading from port cities and coming most often to the American south. The epidemic of 1793 in Philadelphiaclaimed an estimated 4,000 lives between Aug. 1 and Nov. 9 alone, with thousands more deaths in the years that followed. “The Great Fever,” a documentary that is available in many public libraries, tells the history of this disease and its conquest. There is still no cure for yellow fever, which is endemic is some parts of the world, but there is a vaccine and we now know how the disease is spread—by the Aedes Aegypti mosquito, which also carriesdengue and chinkungunya, first seen in the Americas only last year.

Physician-historian Margaret Humphreys, one of the experts who appears in the film, teaches the history of medicine at Duke University in Durham, N.C., and has published on the history of yellow fever and malaria in the U.S., and on medicine during the Civil War. I interviewed Dr. Humphreys about yellow fever in the United States back then—and about Ebola today:

Can you describe what happened during yellow fever outbreaks?

Yellow fever outbreaks always created panic. While physicians debated whether the disease was contagious, the people voted with their feet. Yellow fever causes a dramatic, painful, messy death, with patients screaming in agony and vomiting blood. Physicians had little to offer and were themselves terrified of infection. Such terror shut down communities, including all commerce and most jobs, leaving the poor even more destitute than usual.

What were the consequences of these outbreaks?

Short term, the epidemics of yellow fever in the United States caused thousands of deaths. The commercial impact was even more severe, because fear of the disease blocked trade in places where the virus failed to penetrate. The horrible events forced government response, leading to the funding of a state board of health in Louisiana, the first such entity in the country, in 1859. After the particularly damaging yellow fever outbreak in 1878, Congress created the National Board of Health, the first federal public health agency. It was housed in the Treasury Department, as its duties involved regulating interstate commerce (and stopping the entrance and flow of disease). It survived only a few years but in the late 1880s the fledgling U.S. Public Health Service emerged from the yellow fever outbreak of 1888, and proved its worth in the 1905 outbreak in New Orleans.

What parallels do you see between yellow fever epidemics of the past and the Ebola epidemic today?

I heard a report on NPR about the impact of Ebola on the economies of the countries most affected (Liberia, Sierra Leone, Guinea). Liberian workers usually cross the border into the Ivory Coast to harvest cocoa at this time of year, but that border is sealed to prevent the importation of Ebola. Commercial enterprises within the affected countries are taking a hit that may take years to rebound from. For these very poor countries, as in the 19th century American South, poverty in turn breeds disease. Malaria control has been set back, for example, as unpaid workers can’t afford medication.

Other parallels are tragically obvious—this is a horrible disease, with a high death rate, and its contagiousness seems obvious to caregivers. The choice of abandoning loved ones, and of abandoning the usual death rituals to avoid contagion, must be tearing families apart. I have also heard reports of people blaming the foreign doctors and aid workers who are there to help, claiming that they are in fact a cause of the outbreak. In 1905 New Orleans, when public health workers were treating the neighborhood cisterns to prevent mosquito breeding, Italian immigrants were sure they were poisoning the water, and attacked the water treatment teams. When a disease is this deadly, and the population affected is interacting with medical personnel who hold a different world view on disease causation, such frightening and heartbreaking scenes are likely.

The lines on the tabular situation reports, sent to WHO each day by its country office in Nigeria, have now been full of zeros for 42 days.

WHO officially declares that Nigeria is now free of Ebola virus transmission.

This is a spectacular success story that shows that Ebola can be contained. The story of how Nigeria ended what many believed to be potentially the most explosive Ebola outbreak imaginable is worth telling in detail.

Such a story can help the many other developing countries that are deeply worried by the prospect of an imported Ebola case and eager to improve their preparedness plans. Many wealthy countries, with outstanding health systems, may have something to learn as well.

The complete story also illustrates how Nigeria has come so close to the successful interruption of wild poliovirus transmission from its vast and densely-populated territory.

Saturday, October 18, 2014

While Ebola continues to claim many victims in its epicenter in Western Africa, there is some good news as per the latest WHO press release.

Senegal is now free of Ebola virus transmission

Forty-two days have now passed since the last contact of Senegal’s single confirmed case of Ebola virus disease completed the requisite 21-day monitoring period, under medical supervision, developed no symptoms, and tested negative for the virus.

WHO officially declares Senegal free of Ebola virus transmission.

The response to Senegal’s first case, confirmed on 29 August, on the part of President Macky Sall, the Ministry of Health and Welfare, headed by Dr Awa Coll-Seck, and several other sectors of government, carries some instructive lessons for many other developing countries that are now wisely preparing to respond to an imported case.

Other lessons come from staff at the WHO country office, senior epidemiologists sent to investigate and support the response, and WHO’s many institutional partners in outbreak response.

WHO treated the first case in Senegal as a public health emergency, and responded accordingly.

The most important lesson for the world at large is this: an immediate, broad-based, and well-coordinated response can stop the Ebola virus, carried into a country in an infected traveller, dead in its tracks.

The first case is quickly detected, tested and laboratory-confirmed

The outbreak in Senegal was announced on 29 August, when a case of Ebola virus disease was confirmed in a young man who had travelled to Dakar, by road, from Guinea, where he had had direct contact with an Ebola patient.

Dakar was in a fortunate position: it is home to a world-class Senegalese foundation, the Pasteur Institute and its laboratory. The laboratory is fully approved by WHO to test quickly and reliably for viral haemorrhagic fevers, including a biosafety level IV pathogen like Ebola.

These epidemiologists worked shoulder-to-shoulder with staff from the Ministry of Health, headed by Dr Papa Amadou Diack, the country’s Director-General for health, the WHO country office, headed by Dr Alimata Jeanne Diarra-Nama, and other partners, especially Médecins sans Frontières and the US Centers for Disease Control and Prevention (CDC).

With outbreaks raging just across its borders, Senegal was well-prepared, with a detailed response plan in place as early as March. From the outset, the response was led and coordinated, across multiple government, by Senegal’s President and Prime Minister.

A National Crisis Committee provided the “nerve centre” for the emergency response. Local funds were immediately mobilized to support its work. These funds, supplemented by technical, material, and financial support from multiple partners, enabled immediate activation of the plan.

Despite the fact that a single case had been detected in Dakar, the government decided to deploy the plan nationwide. The whole country moved into a heightened state of alert.

Also critically important early on was the government’s decision to open a humanitarian corridor in Dakar to facilitate the movement and activities of humanitarian agencies. This decision meant that food, medicines, and other essential supplies could seamlessly and efficiently flow into the country.

Senegal defeated the disease. The Ebola virus is gone – for now – from its territory

Wednesday, October 1, 2014

Given that USA has reported the first case of Ebola today ( Times of India - US confirms first case of Ebola) and the fact that there are more than 45000 Indians living in Nigeria which is now in the front lines for Ebola disease, we are going to get it sooner than later.

According to CDC estimates it is likely that more than a million cases of Ebola are going to happen by 2015 (Fox news - Estimating Ebola cases in 2015). Given that US with all its rigorous standards and effective quarantine, and relatively smaller number of individuals in Africa has already reported a diagnosed case of Ebola, I believe that the first confirmed is not far off in India as well.

In fact, what worries me more is that there is possibly already someone infected with Ebola that has slipped through the airport and is infecting people in the community and getting mistreated!

Here is the reason why I think this scenario is scary but possible....

1. We have very poor quarantine & screening facilities. Here is a report from Maharashtra that a PIL had to be filed in the high court for screening facilities to be set up by the Government in Pune & Nagpur airports !

2. Our quarantine centers are dilapidated and understaffed and have poorly motivated and under trained people. While Delhi has created an updated Ebola screening facility , the practical experience of travelers is not very enthusiastic. The facility is crowded, since before the Ebola epidemic it used to cater to about 10-20 patients a month, while now it is required to cater for more than 30 people a day! Also people who are politically connected or serve in high posts in the government have got out of the quarantine without staying the required number of days (as per personal communication)

There are 3-4 beds in every room, and people who have absolutely no fever are also being quarantined in the same facility (for having non govt approved Yellow Fever certificate, or any other medical reason).

Given the close contact of these people, there is every chance that Ebola transmission may actually INCREASE in these quarantine centers if god forbid a case comes to these facilities.

And this is the situation in the 'best' quarantine center in the country! The other centers are likely to be even more poorly equipped and have less chances of containing the disease when it comes here.

3. The incubation period of Ebola is long ... up to 3 weeks. This means that a person coming from Africa may be completely without any symptoms when they are seen at the airport and may develop symptoms like fever, diarrhea vomiting etc even a couple of weeks after landing in India. This is exactly what happened in the case reported from USA.

Now it is very likely that any person falling ill after 2 weeks after coming from Africa will not make a connection between the possibility of Ebola and is even more likely that they would not inform the doctors about the travel from Africa, who would in any case NOT suspect Ebola in this situation. The patient would be inappropriately treated for things like Typhoid and even suspected Dengue, but Ebola is unlikely to be diagnosed in most Indian settings.

By the time this is thought and tests done, others in the family or the hospital may be infected and this could lead to an epidemic of Ebola cases.

We can all imagine what would happen if the disease spreads in our overcrowded country with poor diagnostic facilities, and ramshackle health network. Given a complete absence of any vaccine or specific treatment for Ebola, I can foresee a huge tragedy that is likely to happen in the near future.

Panic stricken people reporting in chaotic surroundings to overburdened government facilities, and overcrowding of our barely functional infectious disease hospitals may actually lead to such a serious problem that our economy may stall, and Modiji's laudable initiative to "Make in India" to improve our Indian economy may be affected as well.

I would recommend a strengthening of our detection infrastructure, separating people in quarantine - those with fever and those without fever are kept in different areas, and telling every one who is coming from Africa to make sure that they report back for any fever related symptom over the next 3 weeks, and following up each of these people diligently.

I believe that only a minor miracle can prevent Ebola from spreading in our country.

About Me

I am a pediatrician based at Mohali, a suburb of chandigarh, North India. I have my own virtual office at www.charakclinics.com; I have been a pediatrician since 1994. I hope to make ths blog a regular feature with tonnes of relevant info for parents, especially in India, because i feel that "informed parents are better parents". My interests include research in OPD practice, specifically new vaccines and travel medicine. I am a member of American Academy of Pediatrics, Indian Academy of Pediatrics, and various travel organizations like International Society for Travel Medicine (ISTM), American Society of Tropical Medicine & Hygiene (ASTMH), International Association for Medical Assistance to Travelers (IAMAT), and British & Global Travel Health Association (BGTHA)